action to resolve conflicting information, and overall treatment of families. Without lead role being clearly identified, the overall results are unacceptable to families of these fallen service members, whose repeated efforts and outcries for assistance have resulted in this subcommittee hearing.

Conflict between family expectations and results is compounded when inconsistencies are issued in final reports. After waiting extended time frames to allow for a comprehensive review involving, presumably, intensive assessment, review, and validation of material and aspects, an expectation of excellence is not met. The cognizant and/or responsible investigation office should and must perform a role of integration before any significant process improvement can be achieved. You see before you the results of this not happening. Each family here can provide specific discussion in this area for their loved one.

I categorically state that in recent final reports received conflicts and errors are not resolved, a rationale is not provided, and multiple reports produced are, at the best, loosely coordinated. In general, we do not believe this result is the intent of existing legislation and policy.

We recognize the uniqueness of each investigation and case. Yet within the Department of Defense and activities supporting this process there is not an overall focal point with clearly identified responsibility to integrate different sources of material and results into a final report provided the family. Instead, each major entity, the service, the investigating office, the medical examiner, and so forth, prepares individual reports for release purposes, each of which is considered conclusive and must be requested separately through the Freedom of Information Act and/or the Privacy Act.

There is a very real turf syndrome noted from a review of different reports which tends to create a hands-off or rote acceptance of material not prepared by the reportee. In short, if I am not responsible, accept it, incorporate it, and move on. This practice reflects profoundly upon the DOD's integrity, and whether occasional occurrences or, as we believe, a systemic issue, this has created a bad apple odor that taints the entire organization and creates a general perception of incompetence. Inadequate results are unconscionable.

There are four broad concerns related to self-inflicted determinations I wish to express which are representative of families gathered here today. The first issue is that the structure of investigations whereby elements are segregated under separate investigative authority precludes objective and comprehensive presentation of all contributing factors to the investigation. Without formal structure and overall focus, investigative reports and results provided families tend to reflect poorly upon values, integrity, and senior command structure of activities involved. Internal review activity is not effective in evaluating and reporting, while simultaneously avoiding culpability issues. Internal service administrative reviews are containment oriented, in that substantive issues are minimized. Criminal investigating office investigations do not provide a rationale, and creates a clear perception of predisposition. Process disconnects are present from incident through closure for

involved activities. Attached to this testimony is an overall process flow chart considered to be representative of this.

Recommendation on this: Improve the process through proactive planning to assure that requirements flow down from top policy to the lowest operational directives. In conjunction with this, vague, superfluous, and conflicting guidance can be corrected or eliminated. View this process as it really is: highly interactive, involving services, criminal investigating offices, medical examiners, armed forces institute of pathology, and many other activities, with the key elements of coordination and communication identified as a must. For a process of this nature, communication and resolution of open and fragmented issues is critical to assure adequate overall results.

Only after making the process capable can evaluation of actual performance be done. Each case reviewed by the DOD Inspector General's office reflects issues of practice which should not have happened. This could be effectively done through a multiservice process team, comprised of the services, the investigating offices, medical community personnel, perhaps even chaired by the DOD IG's office, to review prescribed methods and practices, and subsequently validate actual actions taken from recent cases handled.

Senator KEMPTHORNE. Mr. Casto, it is not a question that we should try to limit any of this testimony. All of you should be given ample opportunity. But again, with your statements that you have given to us, I know that we have made note. There are questions that I certainly want to get to, so if you do not mind, and with all due respect, perhaps you could just summarize the issue and give us the recommendation so that we can cover as much ground as possible in this hearing.

Mr. CASTO. I will be happy to.

Senator KEMPTHORNE. Thank you very much.

Mr. CASTO. I recommend that in these subcommittee review efforts these broad recommendations be considered, since, if implemented, a large portion of concerns can be alleviated. I wish to stress the need for timely action. Families are put on an emotional roller coaster that should not happen. The highs and lows of this cycle forever impacts and changes them as they are drawn into an unfriendly, containment-oriented system. If this is a process, let us treat it as one. It can be greatly improved. I believe that all parties here are sincerely interested in improvement, and committed to action to resolve items presented here today.

In the spirit within which this hearing is held, breaking the silence on these deaths of military personnel which have too long been ignored, we all offer our assistance and input to this process. Thank you, Mr. Chairman.

[The prepared statement of Mr. Casto follows:]

PREPARED STATEMENT SUBMITTED BY CHARLES A. CASTO

Mr. Chairman and Honorable Committee Members: I am very pleased to be able to present information and concerns to you in support of efforts to improve the Military Death Investigation process for those deemed "suicide".

Although the introduction of Public Law 103–160, section 1185 enacted in the National Defense Authorization Act for Fiscal Year 1994 set a positive framework for administratively identifying inadequacies and shortcomings in the death investigation process, much remains to be done to improve the methods and practices used.

In review of the 1994 congressional report and the current Jan 1996 DOD IG report provided by Ms. Hill, a recurring theme of cases discussed seems to involve preexistent or extenuating circumstances that occurred BEFORE THE DEATH INCIDENT, poor handling by MCIOs who do not initiate action to conflicting information, and overall treatment of families. Without a lead role being clearly identified, the overall results are unacceptable to families of these fallen service members whose repeated efforts and outcrys for assistance have resulted in this Subcommittee Hearing.

Conflict between family expectations and results is compounded when inconsistencies are issued in final reports. After waiting extended time frames, to allow for a comprehensive review involving (presumably) intensive assessment, review and validation of material and aspects, an expectation of excellence is not met. The "COGNIZANT and/or RESPONSIBLE" Investigation office should (and must) perform a role of integration before any significant process improvement can be achieved. YOU SEE BEFORE YOU THE RESULTS OF THIS NOT HAPPENING; each family here can provide specific discussion in this area for their loved one.

I categorically state that in recent final reports received. Conflict/errors are not resolved, a rationale is not provided, and multiple reports produced are (at best) loosely coordinated. In general, we do not believe this result is the intent of existing legislation and policy.

We recognize the "uniqueness" of each investigation and case-yet within the Department of Defense and activities supporting this process-there is not an overall focal point with clearly identified responsibility to integrate different sources of material and results into a "FINAL REPORT" provided the family. Instead, each major entity (Service, MCIO, Medical Examiner, etc.) prepares individual reports for release purposes-EACH OF WHICH IS CONSIDERED CONCLUSIVE and must be separately requested through FOIA and/or the Privacy Act! There is a very real "turf" syndrome noted from review of different reports which tends to create a "hands off" or rote acceptance of material not prepared by the reportee. In short, if I'm not responsible, accept it, incorporate it, and move on. This practice reflects profoundly upon the DOD's integrity and whether occasional occurrences or (as we believe) a systemic issue, this has created a bad apple odor that "TAINTS" the entire organization and creates a general perception of incompetence. Inadequate results are unconscionable.

There are four broad concerns related to "SELF INFLICTED” I wish to express which are representative of families gathered here today.

1. Issue:

The structure of investigations whereby elements are segregated under separate investigative authority precludes objective and comprehensive presentation of all contributing factors to the investigation. Without formal structure and overall focus, investigative results provided families tend to reflect poorly upon values, integrity, and senior command structure of activities involved. Internal review activity is not effective in evaluating and reporting while simultaneously avoiding "culpability” issues. Internal service administrative reviews are "containment" oriented in that substantive issues are minimized. MCIO investigations do not provide a rationale and creates a clear perception of predisposition. Process disconnects are present from incident through closure for involved activities. Attached to this testimony is an overall process flowchart considered to be representative.

Recommendation:

Improve the process through proactive planning to assure that requirements flowdown from top policy to the lowest operational directives. In conjunction with this, vague, superfluous, and conflicting guidance can be corrected or eliminated. View this process as it really is HIGHLY INTERACTIVE-involving Services, MCIOS, Medical Examiner's, AFIP, etc.-with the key elements of coordination and communication identified as a "MUST". For a process of this nature, communication and resolution of open and fragmented issues is critical to assure adequate overall results. Only after making the process capable can evaluation of actual performance be done each case reviewed by the DOD Inspector General's office reflects issues of practice which should not have happened.

This could be effectively done through a multiservice process team (Services, MCIOs, Medical community personnel; perhaps chaired by the DODIG office) to review all prescribed methods and practices and subsequently validate actual actions taken from recent cases handled!

2. Issue:

Release of information and material-Following family notification of a death and being provided a copy of the initial casualty report, no information is routinely pro

vided or made available except as specifically requested and/or identified through FOIA.

Recommendation:

As a minimum, provide a copy of the death certificate and body handling paperwork and information prepared to the funeral home conducting services and burial arrangements. At present, only a bill of lading/shipment receipt is provided.

Additionally, the integrity of the victim's remains and handling are of concern. This area should be evaluated and immediate action taken to keep desecration of remains from happening!

3. Issue:

Overall integrated and focused reports of death investigations deemed self injected is not happening. While practices may be largely IAW procedures and prescribed methods, we seem to have lost sight of the process objective in all of the footwork performed. By definition, process inputs are transformed to produce a desired output. Within this cycle a feedback loop for adjustment is critical for controlling the process—this is apparently missing in these cases.

Recommendation:

Establish a single arbitration type review activity (chaired by the DOD IG?) comprised of members of the medical community (specifically including forensic and pathology areas), military services, MCIOS, Veterans Administration, etc. (all users of reports/information) to provide a unified, focused summary that addresses the needs of all parties.

The term arbitration is used because of apparent reluctance and unwillingness of different groups to provide a complete investigative report.

4. Issue:

There is only temporary administrative recourse available via Public Law 103160, Section 1185 for familial concerns and issues.

Recommendation:

Provide an avenue of recourse, either as part of or separate from the Military Justice System, wherein material issues and specific concerns can be formally addressed in a public "forum or environment" by concerned family members.

I request that in your subcommittee review efforts, these broad recommendations be considered since, if implemented, a large portion of concerns could be alleviated. I further stress the need for timely action. Families are put on an emotional roller coaster that should not happen. Each family here can tell you the highs/lows of this cycle which forever impacts and changes them as they are drawn into an unfriendly "containment" oriented system.

In closing, if this is a process, then treat it as one. It can be greatly improved. I believe that all parties involved are sincerely interested in improvement and committed toward action to resolve items presented here today. In the spirit within which this hearing is held today, breaking the silence on these deaths of military personnel which has long been ignored, we all offer our assistance and input. THANK you for the opportunity to be here today.

FAMILY

RECEIPT

EVENTUALLY

REQUESTERDAMÄÄDE:

No information is released after the
initial casualty report unless requested
to the proper/cognizant office!

Senator KEMPTHORNE. Thank you, Mr. Casto. In that spirit, we appreciate all of the comments that are being made here today. Colonel, if you would hold just a moment, I would like to acknowledge that Senator Thurmond, who is the chairman of the Armed Services Committee, has also joined us. Mr. Chairman, are there any comments that you would like to make as this hearing continues?

STATEMENT OF SENATOR STROM THURMOND

Senator THURMOND. Thank you very much, Mr. Chairman. Ladies and gentlemen, I just dropped by to show my interest in this matter. I have another matter going on that I have to go back